Many case managers look to Independent Review Organizations (IROs) to get help with decision-making and for outside perspective from a trusted source. For some, their collaboration is required. So how do you know when it’s time to start working with an IRO? Here are 10 instances which can help you better identify when its time to look for a partner.
1. Costs for treatment are high
Working with an IRO means you can take some of the time allotment off your own full-time staff for claim management–and then you are only paying for the additional support when you need it. No more expensive doctor overhead.
2. Reduced litigation risk
If there’s a chance your case may be litigated, having decision-making processes handled by a third party adds transparency and safeguards your practice. Your IRO can provide all of the proper documentation for the case and can help insure there was no bias when it came to care delivery.
3. Specialized cases
You need a case manager who has the expansive knowledge of how to handle unique and specialized cases and is trained for this difficult role. When you rely on a single doctor or in-house case manager to know all of this information, poor decisions are more likely to occur. IROs provide expertise that comes from working daily in this arena.
4. Risk mitigation
If you have a case that seems fraudulent, IROs can step in to get to the bottom of an issue on both the patient and doctor side of the equation. Because they have no interest in the final decision, fraud is more likely to be exposed by an outside entity.
5. Appeals
If you have cases that are more likely to be appealed, payers want more objective decision making that can’t be influenced by interested parties. A partnership with an IRO shows a provider’s dedication to proper care delivery on a regular basis.
6. Limited staff resources
If your team is struggling to manage the case management side of things, outsourcing can help cut costs and preserve those important time resources. With and IRO, your team can rest assured this part of the equation is being handled (and they can get back to focusing on other work.)
7. Deadlines
If you’re tied to state and federal deadlines, an IRO can make sure you meet those cutoffs every single time. When handled in-house, they’re more apt to be lost in the pile of things to do. It’s just human nature when things get busy!
8. Not enough expertise
Some cases will require insight from specialists–and if you don’t have those on hand, you risk making poor decisions that end up costing you more money in the long run. IROs have an extensive network of doctors and specialists for to call on so that each review is handled with the highest level of expertise.
9. Too much experimentation
If your physicians are prone to recommend experimental treatments, an IRO can help ensure those suggestions stay in the realm of medical necessity. Plus, it removes you from the difficult conversation when a doctor has to be told, “That treatment method isn’t going to work for us.”
10. Revenue cycle
Working with an IRO can help with everything from claim denials to increasing your internal revenue cycle. There’s no bottlenecking that comes from a clog in your claims system when an IRO has a constant watch over it.
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